Stimulus Compromises: Ok, Now I'm Mad

February 5, 2009

Harold Pollack is a public health policy researcher at the University of Chicago's School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies. He is a regular contributor to The Treatment.

While you’ve been preoccupied with Tom Daschle’s taxes and funky glasses, Senate Republicans and moderate Democrats have been nibbling away at the stimulus bill. Reports suggest that this group wants to trim $200 billion. Since the President needs 60 votes, the critics may succeed.

Overall, the stimulus package remains an important and progressive bill. Politics being what it is, neither the House nor the Senate will produce a pork-free package. The various current versions include some pork. The final version will include some pork when the legislating is done. What is remarkable and galling is the way Senate critics focus like a laser beam on the smallest, most defensible, glatt kosher items.

The most ambitious effort to cut the bill is being led by Sens. Ben Nelson (D-Neb.) and Susan Collins (R-Maine), moderates in their parties who share a dislike of the current version. Collins is scheduled to visit Obama at the White House this afternoon. "I'm going to go to him with a list" of suggested deletions, she said….Among the items that the Collins-Nelson initiative is targeting: $1.1 billion for comparative medical research, $350 million for Agriculture Department computers, $75 million to discourage smoking, $20 million in Interior Department funding, $400 million for HIV screening and $650 million for wildlife management.

I don’t know about the Agricultural and Interior Departments or managing wildlife. I do know about the health stuff. These provisions don’t belong on anyone’s list to cut.

Comparative medical research is a high priority by any conceivable measure. Candidate Obama and Candidate McCain both advocated major investments here to improve the quality and cost-effectiveness of care, and they were right. An astonishing proportion of American medical care has never been rigorously evaluated, or outright fails to meet reasonable thresholds of quality and cost-effectiveness.

As Ezekiel Emanuel put it in his book Healthcare, Guaranteed: “The United States spends over $2 trillion on healthcare, about $200 billion on prescription drugs, and nearly $100 billion on medical research and development, but only a paltry $1 billion to evaluate the comparative costs and effectiveness of medical interventions and their influence on health outcomes.”

The two most responsible funding agencies for this research--the National Institutes of Health and Agency for Healthcare Research and Quality—are now getting many more high-quality proposals than they are able to fund. Their peer-review process is rigorous and highly competitive, sometimes excessively so. Many of my junior colleagues are suffering professional setbacks because they cannot find funding for excellent research that would have been supported five or ten years ago. Incidentally, both the loudest and the most dangerously silent opponents of comparative medical research have been surgical subspecialties, medical device manufacturers, and pharmaceutical companies afraid that their ox might be gored.

I suspect comparative medical research will survive because it is visibly central to the President’s health reform efforts. More vulnerable are the offending public health measures. I am no unbiased observer. I have written, here and elsewhere, about the need for expanded public health efforts in both the stimulus package and in the broader healthcare reform. Just yesterday, David Ludwig and I published a commentary in the Journal of the American Medical Association (sadly, behind a firewall) noting anti-obesity measures that would also stimulate the economy. I only wish the House had done more.

Washington conventional wisdom has fastened on HIV/STI/TB prevention and related services as tangential and unworthy stimulus items. (I won’t even discuss family planning, which was dropped with predicable but depressing alacrity.) In policy terms, these efforts are unobjectionable. Inflation-adjusted federal expenditures on HIV prevention have markedly declined since 2002, despite rising numbers of new infections. Our society faces other serious challenge from other sexually-transmitted infections, and from tuberculosis, too. A large body of evidence-based interventions could attack these problems with monies appropriated in the House stimulus bill.

Perversely, the obvious social value of public health investments has become a mark against them in the current stimulus debate. Critics worry that someone might support these policies because they are sensible and humane, not merely because they shovel some quick money into the economy. I guess the charge rings true. Yet as a mechanism of economic stimulus, hiring nurses and counselors to prevent unintended pregnancies or HIV infection is no less worthy than hiring burly construction workers to build a road. Public health measures are a lot cheaper. They are a hell of a lot less likely to stiff taxpayers for an environmentally dicey boondoggle.

It is especially sad that Senators would strip the tiny expenditure of $75 million for smoking cessation services. Smoking remains America’s most prevalent and avoidable cause of premature illness and death. That little measure would have created 1,500 jobs, at precisely the time when many states and localities are cutting back on public health. I admit, 1,500 jobs is not a lot, but we’re only talking about 1/10,000 of the current bill.

Those smoking cessation provisions would also have helped roughly 45,000 people quit smoking, preventing many thousands of smoking-related deaths and serious illnesses. Smoking cessation is far more effective, per dollar spent, in creating jobs and in improving health than just about anything else I can find in the bill’s remaining 99.99 percent of stimulus dollars.

Conservatives and moderates have successfully framed this week’s debate to imply that liberals have larded up the stimulus with special interest pork and spurious, ideologically-driven spending. The real problem is precisely the opposite.

As my colleague Jens Ludwig points out, public health measures are vulnerable because they are not porky enough. They do not slide neatly into the grooves of American interest-group politics. Public health policies have an unfortunate tendency to improve health among diffuse, disorganized, or politically marginal constituencies. These policies provide too little gravy to organized and powerful constituencies. Although many interest groups and many politicians claim to support public health and prevention, few care quite enough to support these values once the shoving starts.